Provider First Line Business Practice Location Address:
725 CENTER AVENUE,
Provider Second Line Business Practice Location Address:
SUITE 7 (CCRI)
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-1972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-6730
Provider Business Practice Location Address Fax Number:
218-236-1481
Provider Enumeration Date:
02/21/2007